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i <br /> Cham-of Custod Number <br /> SECQR Chain-of Custody Record <br /> Field Office o7 7 Additional documents are attached, and are a part of this RArd <br /> ` 57L/dd Job Name � � d Ga <br /> Address b/ Location 1`� ' ��`�'y � Z—y�nkl� <br /> Project #,!97-71//7---7 Task# 4:202— Analysis Request <br /> Project Mana er ^�w,n <br /> Laboratory m y y <br /> V <br /> Turnaround Time _ <br /> r S/ S 'O d j & <br /> Sampler's Name ,� o '0 p 0 0 0 !6 0 5 0 W o R ° <br /> r N p ON N .0 >N 6 0 J 'y `� <br /> Samplers Signature oo —m MCD co a @ <br /> c� m y °o 4) H N o y Comments/ 3 <br /> O LL ON @O NN 00 Qv � V <br /> Sample ID Date Time /Matrix z M m Co. Q �o x� u)�.0.,n ti a M r Instructions z <br /> Special Instructions/Comments Relinquis a Received by Sample Receipt <br /> Sig Sign– Total no of containers <br /> Prrnt� �� o Print Chain of custody seals <br /> Com an S� Company Lal Rec'd in good conditionlcold <br /> Tim a /� Time 5---30 Date - A? a 1 Conforms to record <br /> Relinquished by Received by Client �54:� r` <br /> Sign 5;/ Sign <br /> Print_ �� JJro _ Print Client ContactT <br /> Company S£Go 2 Company rIXeeteX Ao% Cienone <br /> lt Ph �l�'"56(� <br /> Time. ?22 Date 1 1 Time Date <br /> Date Page L of l <br />